Primary Care Physicians Know U.S. Healthcare is Too Aggressive

42% felt that most patients in their own practices receive too much care, only 6% said too little. When asked why some patients received too much care, malpractice concerns, clinical performance measures (i.e. these physician report cards), and lack of time were the most given reasons. They also thought financial incentives caused ologists to over test patients.

It strikes me that for two out of the three causes of too much care, the patient-centered medical home (PCMH) cheerleaders are making things worse, at least many of them (I know of a few exceptions). They insist on robotic quality measures with no way to report exceptions. Many, but not all, of the PCMH pushers also are driving family physicians away from their patients into managerial roles, not creating new payment mechanisms to pay family physicians for the time to do meaningful work.

Until the suits realize it takes two minutes to fill out a consult form, but much more time to perform a procedure in addition to an office visit or deal with a litany of inter-related patient concerns, the full potential of family medicine will not be achieved.

I am really straining to get a perspective on what you are saying here. To lump proponents of medical homes into trivializations such as “cheerleaders” and especially “PCMH-pushers” somewhat concerns me, particularly in light of past communications on where I thought we stood. Now I have to ask – how are you characterizing a PCMH to begin with? Are you putting this into some sort of a cookie-cutter, mechanical box that offers drone-doctoring??

From my view, the medical home is a place where family practice physicians can get to exhibit and offer exactly what this country’s sick, dysfunctional health care system needs. That need is a vital cognitive core of medical practice that DOES place the primary care doctor in a management role – as a manager, counselor and overseer of patients health care that results from the best elements of a physician-patient interface – where a primary care doctor has sufficient time to treat his/her patient with the thoroughness that a true doctor-patient relationship affords. I’ve said it until I’m blue in the face. but I wonder how many get it in this toxic soup of a system we call American healthcare? Only in primary care doctor-patient relationships can we really consider someone to be a doctor’s PATIENT. Everywhere else, it really boils down to the doctor-patient interface as a “case” relationship, and that’s where so much waste comes in. Is a heart surgeon going to be the manager, overseer and counselor to a patient’s total medical needs profile? Heaven’s no! So in the worst-case scenarios, we have multiple maladies being treated by multiple ologists, and let the confusion, overly-diagnostic, over-treating and over-prescribing music begin. All for want of a physician who takes in the big picture with a “patient” and who manages the care of that patient.

Let’s not package this as a notion. ACOs are a notion with a purpose – to gobble up a big piece of the pie for the sake of hospital systems. PCMHs, as I see it, are the places where I think family docs can shine.

I am really straining to get a perspective on what you are saying here. To lump proponents of medical homes into trivializations such as “cheerleaders” and especially “PCMH-pushers” somewhat concerns me, particularly in light of past communications on where I thought we stood. Now I have to ask – how are you characterizing a PCMH to begin with? Are you putting this into some sort of a cookie-cutter, mechanical box that offers drone-doctoring??

From my view, the medical home is a place where family practice physicians can get to exhibit and offer exactly what this country’s sick, dysfunctional health care system needs. That need is a vital cognitive core of medical practice that DOES place the primary care doctor in a management role – as a manager, counselor and overseer of patients health care that results from the best elements of a physician-patient interface – where a primary care doctor has sufficient time to treat his/her patient with the thoroughness that a true doctor-patient relationship affords. I’ve said it until I’m blue in the face. but I wonder how many get it in this toxic soup of a system we call American healthcare? Only in primary care doctor-patient relationships can we really consider someone to be a doctor’s PATIENT. Everywhere else, it really boils down to the doctor-patient interface as a “case” relationship, and that’s where so much waste comes in. Is a heart surgeon going to be the manager, overseer and counselor to a patient’s total medical needs profile? Heaven’s no! So in the worst-case scenarios, we have multiple maladies being treated by multiple ologists, and let the confusion, overly-diagnostic, over-treating and over-prescribing music begin. All for want of a physician who takes in the big picture with a “patient” and who manages the care of that patient.

Let’s not package this as a notion. ACOs are a notion with a purpose – to gobble up a big piece of the pie for the sake of hospital systems. PCMHs are the places where I think family docs can shine.

As a family doctor I just love to get the er reports after my patients go to the er. They all get a cat scan of the brain regardless of reason for visit and they all get screened for heart attack. Talk about over treatment. The big think that I am having problems with is the “quality” stuff; so all of my patients need a HgA1c twice a year regardless of what the first one was!!!!! Every one over 40 who every smoked needs spirometry! What is next???

The key distinction between the current PCMH models (Joint Principles and NCQA Standards) and what we need to make healthcare more affordable isn’t the gizmos and gadgets of the PCMH, but the squishy stuff between the ears of family physicians given enough time to do its job. Nor is it group visits, email visits, disease registries, quality improvement (the way its currently commonly designed), or other distractions.

The article points out how much primary care physicians wish they were paid to spend time with their patients. Innovators such as QuadMed, Group Health Cooperative, and WeCare have figured this out to a large degree by scheduling routine 30 minute visits. (I would do schedule things a little differently, but it’s easy for me to be an armchair quarterback in contrast to their proven record of success).

The important distinction in my head is the PCMH does not equal primary care. The family physician’s brain given time to provide quality care is the solution, most of the other elements of the PCMH are not.

As far as Dr Grundy, his think-tank credentials may be impressive, and tech-savvy and machine ordered processes are undoubtedly a part of his DNA. But heaven help us if IBM ever finds a way for Watson to somehow get his MD – Big Blue will become insufferable. What’s the old adage … “those that can – do, and those that can’t teach (or preach?)”

As I read your insights into the PCMH, I can fully appreciate your thinking about the fate of real doctoring if we don’t stop getting it mired in the PCMH buzzword universe. What should be a simple chart for efficient, evidence-based medicine becomes a mass array of flow charts and boxes.

Were it up to me, I would designate a new acronym. DPCMH – “Doctor-Patient Centered Medical Home”. This model would operate on a set of simple premises:

• A patient needs a doctor who has the time to use the best diagnostic tools of medicine – the physician’s eyes, ears and hands
• The physician and the patient have a real relationship – not a jumbled series of brief encounters
• The physician is paid to ensure the patient dots are connected – all the dots in the appropriate amounts of time required to accomplish that
• Appropriate payment to the physician follows the unbeatable premise of – doing the right thing, at the right time, for the right reasons at the right cost.
• And, since someone has to pay for this (like an employer), use technology to gather facts. Those facts would compare before and after. For the bean-counters we all have to live with, that means showing where all the leaks and hemorrhages were occurring before the DPCMH was adopted, and then how much reduction took place after the DPCMH took effect. Net, net – make the bean counters happy.

That’s the essence of the clinic model you and I have discussed, and it was resoundingly validated in a conversation with a leading third-party administrator of health care plans. I just marvel at how blind employers are to the bleeding taking place, and how inept they are at demanding and evaluating remedies. We are not getting the intelligence data we need to overwhelmingly validate our current ignorance. So instead we conjure up these impressive, complex organisms to put everyone into little process-boxes that gets us away from the critical interfaces that get results – provable results.

What Christopher Gregory describes in his first post is the Platonic ideal of a PCMH. What the AAFP is pushing has almost nothing in common with that (and, as the AAFP is selling the PCMH to insurers, hospitals, etc., “pushing” is the correct word). In the AAFP’s version (see Future of Family Medicine Report 6), the doctor has a larger patient panel, spends less time in patient care, and has shorter appointments. The bulk of health care is provided by various members of the “team.” The doctor is sitting in front of the computer doing patient registries, care management, and all the other data collection tasks that are the heart of the PCMH. The core strength of family medicine – the ongoing one-on-one relationship of physician and patient over time – is of absolutely no value in the PCMH.

It’s no wonder that insurers LOVE this concept. They’re taking it over and running straight to the bank with it. Check out the proceedings of the PCPCC annual session (Dr. Grundy’s organization). Lots and lots about lower payouts (i.e., higher profits) by insurers. Lots of enthusiasm for NP-led PCMHs (even higher profits). Not one mention of fair pay for the doctors for the work they are doing. But we do learn that doctors experienced lower job satisfaction and higher sense of work environment chaos!

The group speak/think at the AAFP on this subject is unbelievable (just check out the reaction to the article in the Annals that was deemed to be less that adequately enthusiastic about the results of the PCMH).